Ureteral Injury During Gynecologic Surgery

Injury to the ureter is one of the most serious complications of gynecologic surgery. Less common than injuries to the bladder or rectum, ureteral injuries are far more serious and troublesome and often are associated with a high morbidity, the formation of ureterovaginal fistulas, and the potential loss of kidney function, especially when recognized postoperatively. For these reasons, injuries to the urinary tract, particularly the ureter, are the most common cause for legal action against gynecologic surgeons.

Despite the close anatomical association between the female reproductive organs and the ureter, injury to the ureter is relatively uncommon. Nevertheless, when a ureteral injury does occur, quick recognition of the problem and a working knowledge of its location and treatment are essential in providing patients with optimal medical care. The purpose of this chapter is to elucidate how and why ureteral injuries occur and to review their surgical and nonsurgical treatments.

History of the Procedure: Berard (1841) and Simon (1869) reported the earliest recorded repairs of ureteral injuries in gynecologic surgery. While the exact details of this procedure are unknown, the ureter and its course were understood poorly. In the early 1900s, Dr John Sampson, then a young faculty member at Johns Hopkins University, conducted the first systematic study of the ureter. During the next 100 years, as the surgical management for gynecologic disease progressed, many contributions were made to the understanding of the etiology, prevention, diagnosis, and treatment of iatrogenic ureteral injuries.

Problem: A significant ureteral injury is defined as any recognized or unrecognized iatrogenic trauma to the ureter that prevents it from functioning properly or effectively. The injury may lead to acute ureteral obstruction (eg, a ureter that is inadvertently ligated) or discontinuity (ie, inadvertent ureteral resection). If an injury to the ureter has occurred and is unrecognized, it may lead to chronic ureteral obstruction (ie, crush injury, ischemia) or the formation of fistulas.

Frequency: The frequency of ureteral injury following gynecologic surgery is approximately 1%, with a higher percentage of injuries occurring during abdominal hysterectomies and partial vaginectomies. Patients who have received pelvic radiation or who have advanced pelvic cancers requiring extensive surgical procedures are more likely to experience a ureteral injury.

The rate of ureteral injuries in laparoscopic procedures varies. While some physicians report that laparoscopic procedures have an equivalent rate of ureteral stricture formation secondary to ureteral injury, other authors argue that the rates for ureteral strictures are significantly higher. More research is necessary before a definitive statement can be made regarding the rates of ureteral injury in laparoscopy.

Etiology: The 6 most common mechanisms of operative ureteral injury are as follows:

Crushing from misapplication of a clamp
Ligation with a suture
Transsection (partial or complete)
Angulation of the ureter with secondary obstruction
Ischemia from ureteral stripping or electrocoagulation
Resection of a segment of ureter

Any combination of these injuries may occur.

Several predisposing factors have been identified in iatrogenic urologic injury. These factors include uterus size larger than 12 weeks' gestation, ovarian cysts 4 cm or larger, endometriosis, pelvic inflammatory disease, prior intra-abdominal operation, radiation therapy, advanced state of malignancy, and anatomical anomalies of the urinary tract. Ureteral injuries can be either expected or unexpected, and they may be the result of carelessness or due to a technically challenging procedure.

Pathophysiology: The pathophysiology of ureteral injury depends upon many factors, including the type of injury and when the injury is identified. A number of consequences may occur after ureteral injury, including spontaneous resolution and healing of the injured ureter, hydronephrosis, ureteral necrosis with urinary extravasation, ureteral stricture formation, and uremia.

Spontaneous resolution and healing

If the injury to the ureter is minor, easily reversible, and noticed immediately, the ureter may heal completely and without consequence. Inadvertent ligation of the ureter is an example of such an injury. If this injury is noticed in a timely fashion, the suture can be cut off the ureter without significant injury.

Hydronephrosis

If complete ligation of the ureter occurs, the urine from the ipsilateral kidney is prevented from draining into the bladder, leading to hydronephrosis and progressive deterioration of ipsilateral renal function. These events may occur with or without symptoms. If the urine in this obstructed system becomes infected, the patient will almost certainly become septic with pyonephrosis.

Ureteral necrosis with urinary extravasation

In complete unrecognized ligation of the ureter, a section of the ureteral wall necroses because of pressure-induced ischemia. The ischemic segment of the ureter eventually weakens, leading to urinary extravasation into the periureteral tissues. If the urinary extravasation drains into the adjacent peritoneum, urinary ascites may develop. If the urinary ascites is infected, peritonitis may ensue. If the peritoneum has remained closed, a urinoma may form in the retroperitoneum.

Ureteral stricture

Ureteral stricture may occur when the adventitial layer of the ureter is stripped or electrocoagulated. When the adventitia, the outer layer of the ureter that contains the ureteral blood supply, is disturbed by either stripping or electrocoagulation, ischemia to a particular segment of ureter may result (see Picture 1). Ischemic strictures of the ureter may develop subsequently, which leads to obstruction and hydronephrosis of the ipsilateral kidney.

Uremia

Uremia results when ureteral injury causes total urinary obstruction. This may result from bilateral ureteral injury or from a unilateral injury occurring in a solitarily functioning kidney. Anuria is the only immediate sign of imminent uremia. These cases require immediate intervention to preserve renal function.

Clinical: Iatrogenic ureteral injury from gynecologic surgery may present either intraoperatively or postoperatively. Intraoperative urologic consultation is obtained when the injury is recognized immediately; these patients are best treated with primary ureteral repair during the same operation. More than 70% of the time, unilateral ureteral injury is noticed postoperatively, when the patient may present with flank pain, prolonged ileus, fever, watery vaginal discharge, or elevated serum creatinine levels. In cases of bilateral ureteral injury, anuria is the first clinical sign.

　

INDICATIONS

The indications for evaluation of ureteral injury following gynecologic procedures include loin or costovertebral angle tenderness, unexplained fever, persistent abdominal distention, unexplained hematuria, escape of watery fluid through the vagina, appearance of lower abdominal or pelvic mass, and oliguria or elevated serum creatinine levels.

RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy: The relevant anatomy of the ureter is shown in Picture 2 and Picture 3. Note the close proximity of the distal ureter to the uterine vessels. This is the site where injuries most commonly occur during gynecologic procedures. The next most commonly injured area is at the pelvic brim, in the area of the infundibulopelvic ligament.

Contraindications: Relative contraindications for immediate operative repair include sepsis, hemodynamic instability, and coagulopathy.

WORKUP

Lab Studies:
　

If the ureteral injury is noted intraoperatively, additional laboratory tests rarely, if ever, are needed. Imaging studies are of greater benefit.

If ureteral injury is suspected postoperatively, laboratory tests, including a CBC with manual differential and an electrolyte panel with BUN and creatinine, are needed to assess for possible infection and renal dysfunction.

In the event that a CT-guided aspiration of an abdominal or pelvic fluid collection has occurred, or if pelvic drain output is high through a surgically placed drain, a creatinine measurement of the fluid may be helpful in distinguishing whether the fluid is urine (ie, elevated creatinine level).

Imaging Studies:
　

If the ureteral injury is noted intraoperatively and additional imaging is necessary to localize the lesion, the best imaging study is retrograde ureteropyelography. By placing a cystoscope in the bladder and cannulating the affected ureteral orifice with a ureteral catheter, dilute Cystografin is injected into the ureter under fluoroscopy or when taking a kidneys, ureters, bladder (KUB) image. If the dye is seen in the renal pelvis without any ureteral extravasation or significant narrowing along the ureter, the ureter is in continuity and may be managed conservatively, with either observation or stent placement.

If ureteral injury is suspected postoperatively, imaging studies evaluating for hydronephrosis, ipsilateral renal function, and continuity of the ureter are necessary. These imaging studies may include an intravenous urogram (IVU), an abdominal and pelvic CT scan with IV contrast, a renal ultrasound, and/or retrograde ureteropyelography.

While the IVU largely has fallen out of favor in the evaluation of stone disease, many urologists believe that an IVU is the best imaging study to evaluate for continuity of the ureter in cases of ureteral injury. Unlike a renal sonogram and a retrograde ureteropyelogram, the IVU assesses for function of the ipsilateral kidney and the drainage of the ureter in a series of sagittal images. Hydronephrosis, ureteral integrity, and any extravasation usually can be seen readily through an IVU.

A CT scan also can assess for both function of the ipsilateral kidney and drainage of the ureter. Because CT images are a series of cross sections, visualizing ureteral integrity and continuity often is more difficult than with an IVU. CT scanning has the advantage of imaging for concomitant conditions at the same time.

Renal ultrasound is perhaps the best noninvasive method to visualize the kidney and shows hydronephrosis with great sensitivity. Renal ultrasound does not assess for kidney function, nor does it assess the continuity of the ureter. Therefore, if renal ultrasonography is performed, retrograde ureteropyelography often is necessary to evaluate the course of the ureter.

Other Tests:
　

If one is unsure whether a ureteral injury has occurred intraoperatively, IV administration of 10 mL of indigo carmine or methylene blue with 20 mg of furosemide may help to localize a ureteral injury. Extravasation of blue dye indicates ureteral discontinuity.

Postoperatively, if any drainage is noted from the vagina, an attempt should be made to diagnose a ureterovaginal or vesicovaginal fistula. This may be accomplished with a bedside test. In this test, a tablet of oral Pyridium is administered. The bladder is instilled via a catheter with saline that is colored with methylene blue. A vaginal tampon is inserted. Since Pyridium turns the urine orange, if an orange liquid is observed on the end of the tampon, a presumptive diagnosis of a ureterovaginal fistula can be made. Alternatively, if the tampon absorbs a blue liquid, the diagnosis of vesicovaginal fistula can be made. However, since both types of fistulas may be present simultaneously, this test may not be completely reliable.

Diagnostic Procedures:
　

If the patient is unsuitable for surgery because of sepsis or hemodynamic instability, urinary diversion in the form of a percutaneous nephrostomy tube placement should be performed. This allows decompression of an enclosed and potentially infected space and helps to treat a urinary source of sepsis.

Histologic Findings: Ureteral injury, very rarely, may be first diagnosed by identifying the ureter histologically in the pathologic specimen.

　

TREATMENT

Medical therapy: No specific medical therapy is warranted for ureteral injury per se; however, potential concomitant conditions of ureteral injury (eg, infection, renal failure) should be treated medically.

Surgical therapy: Depending on the type, duration, and location of the ureteral injury, surgical treatment may range from simple removal of a ligature to ureteroneocystostomy. The most common surgical treatments for ureteral injury are simple removal of a ligature, ureteral stenting, ureteral resection and ureteroureterostomy, transureteroureterostomy, and ureteroneocystostomy.

Observation

If a clamp or ligature constricting the ureter is discovered, the clamp or ligature should be removed immediately, and the ureter should be examined. If ureteral peristalsis is preserved and it is believed that minimal damage has occurred, the ureter injury may be managed with observation.

Ureteral stenting with or without a ureterotomy

If tissue ischemia or a partial transection of the ureteral wall is suspected, a ureteral stent should be placed. The purpose of the stent, which typically is placed cystoscopically, is to act as a structural backbone onto which the healing ureter may mold. It also guarantees drainage of urine from the renal pelvis directly to the urinary bladder. It also can work as a gentle dilator since it moves slightly in an up-and-down motion, associated with breathing, as the kidney unit moves. The use of the stent is thought to minimize the rate of obstruction of a ureteral stricture in the injured area.

Alternatively, a ureterotomy may be made along the length of the injured or strictured section of ureter before placement of a stent. Davis described this technique in 1943 (the Davis intubated ureterotomy) in which a ureterotomy is made and left open over the stent. The ureter eventually heals to form a watertight closure over the stent. The stent is withdrawn 6 weeks after it is placed, as it is estimated that all ureteral healing has occurred by that time.

The principles of the Davis intubated ureterotomy have been extended to endoscopic treatments of ureteral strictures. Ureteroscopic endoureterotomy and Acucise endoureterotomy are 2 modalities that attempt to treat the segment of strictured ureter endoscopically by a longitudinal full-thickness ureteral incision, followed by a stent placement. The success of these procedures closely resembles the success of the open Davis intubated ureterotomy, which approaches 80% patency at 3 years.

Ureteral resection and ureteroureterostomy

If extensive ischemia or necrosis is the result of an injury, the ureter injury is best treated by excising the injured segment of the ureter and reestablishing continuity with the urinary system. If the ureteral injury occurred above the pelvic brim, the simplest reconstruction is a ureteroureterostomy, a procedure that is indicated for injuries to short segments of the ureter (ie, <2 cm), in which an anastomosis is performed between the 2 cut edges of the ureter.

Transureteroureterostomy

If ureteroureterostomy cannot be performed technically and the defect is too proximal in the ureter for a ureteroneocystostomy, a transureteroureterostomy may be performed. Absolute contraindications for transureteroureterostomy include urothelial cancer, contralateral reflux, pelvic irradiation, retroperitoneal fibrosis, or chronic pyelonephritis. Stone disease, which formerly was considered an absolute contraindication, is now considered a relative contraindication by some urologists, based on the current ability to prevent stone formation in over 90% of patients with medical therapy.

Ureteroneocystostomy

If the ureteral injury occurred below the pelvic brim, where visualization of the ureter is difficult and where the vesical pedicles overlie the ureter, ureteroureterostomy often is too difficult to perform. In these cases, 2 types of ureteroneocystostomy procedures are indicated, either a psoas hitch or a Boari flap, in which the bladder is mobilized to reach the easily identifiable ureter proximal to the injury. Boari flaps are contraindicated in patients with prior pelvic radiation, a history of bladder cancer, or any condition with a thick, hypertrophied bladder wall.

Preoperative details: If urologic consultation is indicated intraoperatively, the urologist dictates no specific preoperative preparation.

If a ureteral injury is identified after the patient is stabilized from the initial gynecologic operation, a discussion is conducted regarding the possible treatment options. Preoperative antibiotics that target urinary organisms should be administered. If patients are persistently febrile from a potentially infected and obstructed renal unit, percutaneous nephrostomy on the affected side may be indicated. Pertinent radiographic studies (eg, IVU, CT scan) may be used to help define the location of ureteral injury preoperatively.

Intraoperative details:

Ureteral stent placement with or without ureterotomy

After the perineum is prepared and draped in the standard sterile manner, and while the patient is sedated adequately or anesthetized, a cystoscope is inserted into the bladder.

After the bladder is examined and the ureteral orifices are identified, the ureteral orifice on the side of the injury is cannulated with a ureteral catheter. A dilute Cystografin-gentamicin mixture is injected slowly through the ureteral catheter under fluoroscopy, revealing the course of the ureter and identifying potential sites of injury.

A Teflon-coated guidewire is placed under fluoroscopic guidance through the ureteral catheter and up the ureter into the renal pelvis. A double-J stent is placed over the wire and is pushed so that its proximal J-hook is placed within the renal pelvis and its distal J-hook is within the bladder. Then, the wire is pulled, and the stent position is reaffirmed fluoroscopically. Proper length of the stent can be estimated from the measured length of the ureter on retrograde pyelography from the ureteral orifice to the ureteropelvic junction. Allowing for roughly 10% magnification from the x-ray, subtract 2-3 cm and select that length ureteral stent. If, after placement, the stent is not well positioned due to inadequate or surplus length, itis best to replace it with a stent of proper dimensions.

If an endoscopic ureterotomy is to be made, prior to placing the stent, a retrograde pyelogram is performed (as discussed above) to delineate the ureteral anatomy, and a Teflon-coated guidewire, acting as a safety wire, is positioned into the renal pelvis and out through the urethra.

With an ureteroscopic endoureterotomy, a rigid ureteroscope is then placed through the ureteral orifice and into the ureter lumen, until the ureteral lesion can be visualized. The ureteral stricture is then cut with a probe from a number of cutting modalities, including Holmium laser or electrocautery. A full-thickness incision through the ureteral wall is made until periureteral fat is visualized. Retrograde pyelography is performed; extravasation of contrast outside the ureter should be seen. A wide-caliber ureteral stent is then placed (usually 8F) in the fashion described above.

If an Acucise endoureterotomy is performed, the Acucise device is placed over the safety wire. Once position is confirmed via fluoroscopic guidance and the orientation of the cut is set, the Acucise balloon is inflated and electrocautery is instituted. The Acucise device is withdrawn, a retrograde pyelogram is performed to confirm extravasation, and a wide-caliber ureteral stent is placed in the fashion described above.

The formal Davis intubated ureterotomy typically is performed intraoperatively only when urologic consultation is called for while the patient is open. In this case, the injured ureter is cut sharply in a longitudinal fashion. A stent then can be placed to the kidney and bladder through the ureteral incision.

Ureteroureterostomy

If the urologist is asked to evaluate the ureteral lesion intraoperatively, further dissection of the existing exposure often is necessary, because the lack of exposure is the most likely contributor to the injury. Additional blunt and sharp dissection often is necessary to adequately identify the ureter and its course.

If the ureteral injury is discovered after the initial gynecologic procedure, the urologist must decide whether to enter through the original incision and approach the ureter transperitoneally or to make a new incision and approach the ureter using a retroperitoneal approach. Either approach is acceptable, and each has distinct advantages and disadvantages.

If one decides to enter through a previous midline incision, intraperitoneal adhesions may complicate the dissection; however, this approach spares the patient an additional incision.

In contrast, if a modified Gibson incision is made to approach the ureter retroperitoneally, the dissection may be less challenging technically because it avoids the adhesions of the peritoneal cavity, but the patient is left with an additional incision.

Regardless of the approach, a Foley catheter is placed and the patient is prepared and draped in a sterile manner.

In the transperitoneal approach, an incision is made though the scar of the old incision. The dissection is extended down to the peritoneal cavity, and, once the small bowel and colon are identified, a vertical incision is made along the left side of the small bowel mesentery. Blunt dissection is performed in the retroperitoneum until the desired ureter is identified. If the inferior mesenteric artery limits the exposure, it can be divided without consequence. If the left lower ureter is the area of the injury, the sigmoid can be mobilized medially to gain adequate exposure.

In the retroperitoneal approach, after the incision is made, the external oblique, internal oblique, and transversus abdominus muscles are dissected in a muscle-splitting manner. Once the transversalis fascia is incised, take care not to enter the peritoneal cavity. The peritoneum and its contents are retracted medially, and the ureter is located in its extraperitoneal position.

The ureter most consistently is found at the bifurcation of the common iliac artery, but it often can be difficult to identify, especially when dilated. Steps that can differentiate the ureter from a blood vessel with a similar appearance include pinching the structure with forceps and watching for peristalsis. If peristalsis occurs, the ureter has been identified. Additionally, a fine needle can be placed into the lumen of the questionable structure. If urine is retrieved through aspiration, the ureter has been identified; if blood is aspirated, the structure is a blood vessel.

Once the ureter is identified and dissected from its surrounding tissues, the diseased segment is excised. Take particular care not to disrupt the adventitia of the ureter, because its blood supply is contained within this layer. If difficulty is encountered in identifying the diseased segment, retrograde ureteropyelography can be performed to aid in localizing the lesion. Another option is to place a ureteral catheter cystoscopically up to the lesion, then the ureteral catheter can be palpated during the ureteral dissection.

Stay sutures are placed in each end of the ureter, and the ureter is mobilized enough so that a tension-free anastomosis can be performed. Simple ureteroureterostomy typically is performed for ureteral lesions shorter than 2 cm. If the lesion is longer than 2 cm, or if it appears that the ureteral ends will not come together without tension, seek an alternative surgical approach. Options include further mobilization of the ureter, mobilization of the ipsilateral kidney, transureteroureterostomy, ureteroneocystostomy, ileal ureter interposition, or a combination of the above.

Once the ureter appears to have enough length to be anastomosed without tension, both ureteral ends are spatulated. Two 5-0 absorbable sutures are placed in through the apex of the spatulated side of one ureter and out through the nonspatulated side of the opposite ureter. Each suture is tied, and a running stitch is performed on one half of the ureter. The same steps are performed to complete the anastomosis on the opposite half of the anastomosis.

Before completion of the second half, a double-J ureteral stent is placed by first placing a 0.038-cm Teflon-coated guide wire caudally and passing a standard 7F double-J stent over the wire. The wire is pulled after the position of the distal portion of the stent is confirmed within the bladder. Next, a small hole is made within the stent, such that the wire can be passed cephalad, placed into the proximal tip of the stent, and come out of the created hole in the side of the stent. Once the position of the cephalad tip in the renal pelvis is confirmed, the wire is pulled, leaving a well-positioned stent.

After the anastomosis is completed, a Penrose drain or a Jackson-Pratt (JP) drain is placed in the retroperitoneum and is brought out through the skin. Omentum may be retrieved from a small incision in the posterior peritoneum and can be used to wrap the repair. Adjacent retroperitoneal fat may be used. The anterior abdominal fascia and skin are closed.

Transureteroureterostomy

A transureteroureterostomy is approached best via a midline incision and can be performed using both intraperitoneal and extraperitoneal approaches. A left-to-right intraperitoneal transureteroureterostomy is described.

After a Foley catheter is placed and the patient is prepared and draped in a sterile manner, a midline incision is made, and the peritoneal cavity is opened. The small bowel is packed medially, and the posterior peritoneum lateral to the sigmoid and descending colon is incised to expose the ureter. The ureter is dissected, preserving its adventitia. The diseased portion of the ureter is identified, and a clamp is placed on the ureter proximal to the diseased portion. The diseased portion of ureter is excised, a stay stitch is placed on the proximal segment of the ureter, and the distal stump is ligated. The proximal ureter is dissected for a length of approximately 9-12 cm, while the adventitial vessels are preserved.

Attention then is turned to exposing the right ureter. The ascending colon is retracted medially while an incision is made through the posterior peritoneum lateral to the colon. Blunt dissection aids in the identification of the ureter. Approximately 4-6 cm above the level of transection of the left ureter, the right ureter is exposed to make room for an anastomosis.

A retroperitoneal tunnel is created via blunt dissection, and the left ureter is pulled through the tunnel by the stay suture. When the left ureter is pulled through, taking care to not to wedge the ureter between the inferior mesenteric artery (IMA) and the aorta is important, because obstruction may result. Instead, the ureter should be passed either over or under the IMA and should not be angulated or under any tension. If the ureter is too short and a tension-free anastomosis can only be performed with the ureter firmly wedged between the IMA and the aorta, it is appropriate to consider ligation of the IMA. If this maneuver is not performed and the ureter is left firmly between the IMA and the aorta, a fibrous reaction of the ureter typically occurs, which causes an obstruction that must be treated later with a surgical procedure.

The tip of the left ureter is spatulated, and the medial wall of the right ureter is incised using a hook blade for a distance just longer than the diameter of the lumen of the left ureter. Using 4-0 or 5-0 absorbable suture material, a suture is placed at each end of the ureteral incision from the outside in. Each stitch is run over the course of one half of the anastomosis. Before finishing the second side of the anastomosis, a stent is placed along the entire right ureter using the technique described in ureteral stent placement. The 2 stitches are tied to each other.

After the anastomosis is completed, a Penrose drain or a JP drain is placed in the retroperitoneum and is brought out through the skin. Omentum or any adjacent retroperitoneal fat may be used to wrap the repair. The anterior abdominal fascia and skin are closed.

Psoas hitch

After a Foley catheter is placed and the patient is prepared and draped in a sterile manner, various incisions are acceptable, including a midline, a Pfannenstiel, or a suprapubic V-shaped incision. A midline incision is preferred if the patient has a preexisting midline scar from a previous gynecologic operation. If entering the peritoneal cavity can be avoided, this incision is preferred.

The peritoneal reflection is dissected off the bladder. Some advocate saline installation in the subperitoneal connective tissue as a way of facilitating this portion of the dissection. If a peritoneal defect is encountered, it can be closed with a running chromic suture. Once the peritoneum is dissected off the bladder, the peritoneum can be reflected medially.

Attention then is turned to dissection and excision of the diseased ureteral segment. The diseased portion of the ureter is identified, and a clamp is placed on the ureter proximal to it. A diseased portion of ureter is excised, a stay stitch is placed on the proximal segment of the ureter, and the distal stump is ligated.

The superior pedicle of the bladder is ligated on the ipsilateral side, and the bladder wall is incised transversely, a little more than halfway around the bladder, in an oblique manner across the middle of its anterior wall at the level of its maximum diameter. When this horizontal incision is closed vertically, the effect of the incision is the elongation of the anterior wall of the bladder so that the apex of the bladder can be positioned and fixed above the iliac vessels.

After the bladder incision is made, 2 fingers are placed into the bladder to elevate it to the level of the proximal end of the ureter. If the bladder does not reach the proximal ureter, several steps can be performed for additional length. These steps include extending the bladder wall incision laterally to obtain further length, or the peritoneum and connective tissue from the pelvic and lateral walls may be dissected from the contralateral side of the bladder. This dissection may require ligation and division of the superior vesical pedicle on the contralateral side.

Once adequate mobilization of the bladder has occurred, the bladder is held against the tendinous portion of the psoas minor muscle without tension. Prolene sutures (2-0) are sutured into the bladder wall and to the tendon to fix the bladder in place.

With the bladder open, attention is turned to the ureteral reimplant. An incision is made in the bladder mucosa at the proposed site of the new ureteral orifice. A submucosal dissection occurs approximately 3 cm from the incision site so that a tunnel is created. Lahey scissors may be used to facilitate this dissection. After achieving a 3-cm tunnel length, the scissors are inverted and the tips are pushed through the bladder wall. An 8F feeding tube is passed over the scissor blades, and the stay suture on the proximal tip of the ureter is tied to the other end of the catheter so that traction on the catheter draws the ureter into the bladder. The ureteral tip is trimmed obliquely, and 4-6 absorbable sutures (4-0) are used to fix the ureter to the bladder mucosa. The ureteral adventitia is tacked to the extravesical bladder wall with several 4-0 absorbable sutures. A double-J ureteral stent may be placed at this time.

A nontunneled reimplant also is an acceptable choice in most adults if ureteral length is insufficient. The end of the ureter can be reflected back after making a small longitudinal incision from the tip proximally about 1.5 cm. This will make the end of the ureter into a nonrefluxing nipple, which is useful when there is inadequate length for an antirefluxing submucosal tunnel.

After completing the reimplant, 2 fingers are placed within the bladder, while 5 or 6 absorbable sutures (2-0) are placed within the bladder muscle, the psoas muscle, and the psoas minor tendon, paying specific attention not to suture the genitofemoral nerve. Alternatively, sutures also may take deep bites in the muscle itself. The bladder is closed with a 3-0 running absorbable suture on the mucosa and a running 2-0 suture incorporating the bladder muscle and adventitial layers. A Penrose drain or a JP drain is placed in the retroperitoneum next to the bladder closure. The anterior abdominal fascia and the skin then are closed.

Boari flap

After preparing and draping the patient, a midline or Pfannenstiel incision is made. Once the transversalis fascia is incised, the ureter may be approached either transperitoneally or retroperitoneally. In the transperitoneal approach, the peritoneal cavity is entered, the sigmoid or cecum is reflected medially, the posterior peritoneum is incised, and the ureter is identified. In the retroperitoneal approach, care is taken not to enter the peritoneal cavity, the peritoneum is mobilized medially, and the ureter is identified and exposed. A stay stitch is placed in healthy ureter tissue just proximal to the injury. The remaining end of the ureter is tied off.

The peritoneum is then dissected from the wall of the bladder. This dissection may be facilitated with hydrodissection, in which saline is injected subperitoneally, separating the peritoneal layer from the muscle layers of the bladder.

The necessary length of the bladder flap (ie, the distance between the posterior wall of the bladder and the end of the healthy proximal ureter) is measured with umbilical tape, the bladder is one half full of saline, and the length and shape of the bladder flap are planned. To measure accurately on the dome of the bladder, several stay stitches are placed at the base of the proposed bladder flap and at the apex. The bladder flap should be planned with a large base, because the base will contain the blood supply for the flap. The length of the bladder flap (ie, the distance between the base and apex) should equal the distance between the posterior wall of the bladder and the end of the healthy proximal ureter. The width of the apex should be at least 3 times the diameter of the ureter to prevent constriction after the flap is tubularized. Avoid scarred areas of the bladder.

After proper planning, an outline of the flap is made in the bladder wall with coagulating current, and the bladder flap is remeasured. If the measurements are satisfactory, the bladder flap is cut via cutting current, and the concomitant bleeding vessels are coagulated (see Picture 4).

After the bladder flap is turned superiorly, Lahey scissors are used to prepare a ureteral tunnel. The tunnel should be at least 3 cm long and is created by placing the Lahey scissors submucosally at the apex of the flap, tunneling the appropriate distance and coming out through the mucosa. Submucosal injection of saline may aid in this dissection. An 8F feeding tube is pulled through the tunnel by the scissors and the stay suture on the proximal ureter is tied to the feeding tube after the ureteral end is spatulated. The feeding tube is pulled toward the bladder, followed by the ureter. The stay suture is cut after the ureter has traveled completely through the tunnel.

The bladder flap is sutured to the psoas tendon of the psoas minor with a few 2-0 absorbable sutures. These sutures fix the flap in place to prevent tension on the ureteral anastomosis.

The ureter is anastomosed to the bladder mucosa with several 4-0 absorbable sutures. A few of the sutures should include the muscle layer of the bladder to fix the ureter into place. An 8F feeding tube is passed up the ureter into the renal pelvis and out through the bladder and body wall.

Before closing the bladder, a large suprapubic tube is placed, ie, either a 22-24F Malecot or Foley. Then, the bladder is closed by approximating the bladder mucosa with a 3-0 absorbable running suture followed by a second row of running sutures, which approximates the muscularis and adventitial layers. A few absorbable sutures (5-0) can be placed to approximate the distal end of the flap to the adventitia of the ureter. If a transperitoneal approach is used, close the peritoneum and then place a Penrose or a JP drain retroperitoneally adjacent to the bladder closure. The anterior abdominal fascia and skin are closed.

Postoperative details:

Ureteral stent

After recovering from anesthesia, and when the patient is in suitable condition, the patient may be discharged with instructions to return to the clinic in 14-21 days, when the stent will be removed. The patient is discharged with 3 days of antibiotics (eg, Bactrim, nitrofurantoin, Cipro) and oral analgesics for potential bouts of discomfort from the stent.

Ureteroureterostomy, transureteroureterostomy, psoas hitch, and Boari flap

Patients who underwent a transperitoneal approach are kept on a regimen of nothing by mouth (NPO) for the first day after surgery. Subsequently, signs of bowel function are monitored routinely. Once bowel sounds are present, the diet is advanced to clear liquids, and when the patient passes flatus, a regular diet is instituted.

Patients who undergo a retroperitoneal approach are started on clear liquids on the first day after surgery unless they are nauseous. Their diets also are advanced when they have passed flatus.

All patients receive a patient-controlled anesthetic (PCA) pump postoperatively unless they had an epidural catheter placed intraoperatively, then they are given an epidural pump. Oral analgesics are administered after patients tolerate a regular diet.

All patients receive a 24-hour course of IV antibiotics to prevent wound infections.

Patients are encouraged to ambulate on the first day after surgery. Once the pain is controlled with oral analgesics and patients are tolerating a regular diet, they are eligible for discharge, with or without their drains. If drains are not removed in the hospital, set appointments to assess patients and their drains in the clinic.

Follow-up care: In patients who do not require a cystotomy, the Foley catheter or suprapubic tube is left to drain the bladder until the drain output from the Penrose or JP drain is less than 30 cc per day. If this is achieved, the Foley catheter can be removed or the suprapubic tube can be clamped, and the output from the Penrose or JP drain is monitored. If no drainage occurs, the drain can be removed. If drainage increases from the previous level, the Foley catheter is replaced, or the suprapubic tube is unclamped. After several days, the same sequence of events occurs to determine whether the ureter has healed completely. If a stent or feeding tube is used, it can be removed 7-10 days after surgery.

In patients requiring a cystotomy, the Foley catheter or suprapubic tube is left in place for 7-10 days after surgery, at which time a cystogram usually is performed. If no extravasation is observed during the cystogram, the Foley catheter or suprapubic tube can be removed. At the same time, the outputs from the Penrose or JP drain are monitored. If no drainage occurs, the drain can be removed. If drain output increases from the previous level, the Foley catheter is replaced. After several days, the same sequence of events occurs to determine whether the ureter has healed completely. If a stent is used, the stent is removed 10-14 days after surgery.

COMPLICATIONS

Excess drainage

The most common postoperative complication is excess drainage from the Penrose or JP drain. This may indicate the presence of a significant urine leak, either at the ureteral anastomosis or at the bladder closure.

Often, if the peritoneum is not closed or is closed incompletely, peritoneal fluid leaks from the drain, which may confound the situation. Although intraoperative efforts are made to avoid this situation, if one needs to differentiate a urine leak from peritoneal fluid, the fluid may be tested for the creatinine level. If the creatinine level is significantly greater than the serum creatinine measurement, a urine leak is suspected. If the fluid creatinine level is identical to the serum creatinine measurement, the fluid is transudative in nature and likely is peritoneal fluid.

The treatment for most cases of excess drainage is observation. Most often, the drainage tapers with time as the ureteral or bladder wall heals and seals the urine from the drain.

Persistent, long-term output from drain occurs occasionally and implies obstruction either at or beyond the anastomotic site. The most common causes of obstruction are a lack of bladder decompression, stricture at the anastomotic site, or technical error.

Urinary tract infections

Urinary tract infections (UTIs) may occur immediately postoperatively, especially after the removal of an indwelling stent. UTIs are easily treated with oral antibiotics.

Ureteral obstruction or reflux

The most common complications of tunneled ureteroneocystostomy are ureteral obstruction or reflux.

Immediately postoperative obstruction can be a result of either edema of the ureter or technical errors (eg, constricting ureteral tunnel, ureteral angulation during fixation of the bladder). If obstruction occurs later in the postoperative course, a ureteral stricture must be considered. Ureteral strictures typically occur at the distal segment of the ureter and most often are due to ischemia. These strictures can be refractory to endoscopic management; when this is the case, repeat ureteroneocystostomy may be considered.

If the ureteral tunnel is too short, reflux can occur. Unless systemic adverse effects from the reflux occur (eg, recurrent bouts of pyelonephritis, worsening renal function), reflux typically is managed conservatively with observation.

Boari flap complications

Complications specific to Boari flaps include ischemia of the flap, reduced lumen size of the flap secondary to thickened bladder wall, and reflux.

Because the blood supply of the Boari flap emanates from its base, the presence of any devascularization injury of the bladder base may cause flap ischemia and eventual necrosis.

The most common cause of flap ischemia is previous pelvic radiation; for this reason, Boari flaps are contraindicated in patients who have received radiation therapy.

Another possible cause of complications is that the bladder base that was created is too narrow, resulting in an inadequate blood supply to the distal end of the flap.

Yet another complication is that the bladder wall is too thick to form an adequate lumen for the implanted ureter. This situation should be assessed intraoperatively, and, if found, a Boari flap should not be performed.

OUTCOME AND PROGNOSIS

Section 8 of 11

Few recent studies address the outcome and prognosis of ureteral injury, but older studies show that all of the surgical treatments mentioned are effective in treating ureteral injury.

Ureteral stents have been shown repeatedly to act as an excellent scaffolding mechanism when a partial ureteral distraction has occurred, with excellent long-term patency rates. In fact, the Davis intubated ureterotomy, which is the basis for current endourologic treatment of ureteral stricture disease, is aimed at incising a full-thickness portion of ureteral wall, followed by ureteral stent placement. As the ureter heals around the stent, the ureteral lumen is larger when compared to the size of the pretreated ureteral lumen.

The urologic literature comprehensively documents the data regarding the efficacy of ureteroureterostomy in the treatment of ureteral injury. Initial studies regarding ureteroureterostomy focused on the operative technique and asked what type of anastomosis was superior. End-to-end, side-to-side, end-to-side, spatulated, unspatulated, watertight, and loose approximation anastomoses were attempted. These efforts led to broad acceptance of spatulated watertight anastomoses, with or without stents, as the best ureteral reconstruction technique with regard to long-term outcome.

The literature also demonstrates the long-term efficacy of transureteroureterostomy. Hodges et al reported that of 100 patients accrued over a 25-year period who had been treated with transureteroureterostomy for various conditions, including ureteral stricture and intraoperative ureteral injury, 77 patients had no complications postoperatively. Of the 23 patients with complications, 5 patients had acute pyelonephritis, 3 patients had tumor blockage at the anastomotic site, 2 patients had IMA syndrome, and 2 patients had subsequent reflux of the normal ureter. In this study, 97% of patients had normal bilateral kidneys after a follow-up period of 1-23 years.

In a recent study by Mathews et al, the psoas hitch reimplantation was shown to be a successful technique for reestablishing ureteral continuity after distal ureteral injury. In their study of 20 patients who underwent psoas hitch reimplantation for various conditions, 13 patients had iatrogenic injuries during surgery, and 17 patients (85%) required no further intervention for urological problems and retained normal renal function after an average follow-up period of 6 years (range: 1-14 years). The authors conclude that psoas hitch reimplantation is an excellent treatment option for distal ureteral injuries.

In 1975, Konigsberg, et al reported on a series of patients; 15 of 21 patients studied had fair or excellent results for an average of 27 months after Boari flap reconstruction. Of the patients who had poor results, 2 patients had previous pelvic radiation, 2 patients had bladder carcinoma that recurred in the flap, and 2 patients had a flap that was not fixed to the psoas muscle. With the benefit of modern indications for the use of Boari flaps, fewer poor results have occurred, although increased risk exists for bladder necrosis, given the dissection needed to create the flap. As a result of this risk and other technical considerations, many urologists opt for the psoas hitch reimplant as their first choice in ureteral reconstruction after a distal ureteral injury.

FUTURE AND CONTROVERSIES

The future of distal ureteral injuries is exciting, and the use of new technology may change the management of distal ureteral injuries entirely. Recently, with the introduction of subintestinal submucosa (SIS) to be used as a tissue scaffold, a new modality to treat ureteral injuries has emerged. While no current studies are being performed using SIS for the treatment of distal ureteral injuries, the placement of SIS may serve as a healing bridge between 2 injured ureteral ends. Although SIS will not drastically affect the management of short ureteral injuries or strictures, it may be useful in treating longer ureteral defects.

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